Friday, June 30, 2006

According to an Associated Press report that was published or cited in a number of papers (including the St. Petersburg Times), the Surgeon General's advice to Americans is to "Stay Away from Smokers."

The St. Petersburg Times headline: "For your health, stay away from smokers."

An Associated Press article appearing in the Chicago Tribune reported that the Surgeon General summed up the entire report with the advice that Americans should stay away from smokers: "Surgeon General sums up massive report with this advice: 'Stay away from smokers.'"

The Rest of the Story

I want to comment on two aspects of this story.

First, I don't think that "stay away from smokers" is the appropriate message to be giving the American public. 'Stay away from secondhand smoke', perhaps, or 'stay away from smokers who are smoking', but not 'stay away from smokers'.

The message as it was apparently delivered seems to me to ostracize and isolate smokers and make them social pariahs, who nobody should even be near. What a lonely life it would be for smokers if we actually heeded this advice. And what a lonely life for the spouses and other family members of smokers who could not go near them if they took this advice.

I think that we can give the Surgeon General the benefit of the doubt and assume that he misspoke and this is not what he really meant. We can assume that what he actually meant was that nonsmokers should stay away from people who are smoking - from secondhand smoke.

Nevertheless, the way in which the message did come across is really problematic to me. Do we really benefit from having headlines all across the country imploring people to keep away from smokers? Does this not tend to stigmatize smokers and cast them as social pariahs and outcasts who are not even worthy of human contact and companionship? Does it not emphasize that the problem is one of a bad lifestyle choice rather than an environmental and occupational health issue? Does it not de-value the lives of smokers?

I'm sure that it wasn't intended to come out this way, but it did and we have to deal with the consequences of this being the primary message that "sums up" the entire report.

Do you mean to tell me that the message that is being carried to the public as summing up the entire report is that smokers should really be social outcasts that no one should go near? Again, I'm not saying that was the intent, but it appears it was the effect.

I think that's a shame, because there are a lot more appropriate and important messages that could and should come from the report than that one.

Second, this primary message of the communications about the findings of the report seems, at least in my eyes, to contradict the very title of the report: "The Health Consequences of Involuntary Exposure to Tobacco Smoke." If secondhand smoke exposure is involuntary, then people do not have a choice about avoiding it. If people are able to heed the Surgeon General's advice about staying away from smokers, then is it not true that their secondhand smoke exposure is not involuntary at all?

It occurs to me that you can't have it both ways. You can't propose as a solution to the problem that people stay away from smokers and at the same time try to convince us that exposure to secondhand smoke is involuntary. If people can avoid it by staying away from smokers, then is it not voluntary? If simply avoiding the smoke is the appropriate solution, then isn't the problem actually one of voluntary exposure to secondhand smoke?

The materials accompanying the Surgeon General's report are laced with advice to the public to avoid exposure to secondhand smoke. The brochure that accompanies the report instructs people how to protect themselves from the hazard discussed in the 727-page report. And the advice given is: "do not breathe secondhand smoke." "Visit smoke-free restaurants and public places." "Ask people not to smoke around you and your children." "Do not allow anyone to smoke near your child." "Use a smoke-free day care center." "Do not take your child to restaurants or other indoor public places that allow smoking." "Teach older kids to stay away from secondhand smoke." "Choose restaurants and bars that are smoke-free." "Be very careful not to go where [you] will be around secondhand smoke."

If this is the appropriate solution to what is cast as being a devastating public health problem, then isn't the title of the report misleading? Doesn't this advice cast secondhand smoke exposure as being largely voluntary? If you can choose to avoid it, then you're not involuntarily exposed.

My point here is that, once again, the communications surrounding the report are inconsistent with the report itself. If the solution we are proposing to the public is that they should "stay away from smokers," then isn't the problem one of voluntary exposure, and what we're trying to do is to shift the decision that people are making from one of being around smoke to one of avoiding smoke? Then why title the report "involuntary exposure to tobacco smoke?"

I'm not arguing here either that secondhand smoke exposure is truly voluntary or that telling people to avoid secondhand smoke is inappropriate. I'm simply pointing out the inconsistency of the communication to the public in light of the title and findings of the Surgeon General's report.

Frankly, if secondhand smoke is as bad as the Surgeon General tells us (even a brief exposure causes heart disease and lung cancer, everyone is at risk, there is no safe level of exposure, even drifting smoke outdoors is a major problem, even smoke coming out of a building through the doorway is a serious concern), then I would view it as irresponsible for the leading health officer of the nation to do anything other than recommend that smoking be banned completely.

How can you get up in front of the American people and try to convince them that secondhand smoke is so toxic and so carcinogenic that even a brief exposure is enough to cause fatal heart attacks and lung cancer, and then instruct them that the appropriate solution is simply: "don't breathe secondhand smoke?" And how can you argue that the appropriate solution is to simply choose to avoid secondhand smoke exposure if the problem you are talking about is involuntary?

To be honest, it seems to me that any toxic substance that is capable of causing lung cancer and heart disease from just a brief exposure should be banned - no questions asked. To take any other action seems irresponsible.

Do you know how sometimes when you're doing something that you're pretty sure is the right thing, you have second thoughts and begin to doubt yourself? Early on in the history of this blog, I found myself in such a situation. It struck me that a lot of what I was observing in the anti-smoking movement seemed quite inappropriate and deserving of public comment. However, part of me wasn't sure. I viewed this blog as something of an experiment. I would write about some of these issues and see what happened. I certainly had no intention that the blog would grow and develop and even be in existence 15 months after it began.

Over the past months, something has happened which has convinced me that this is real, that these things are really going on, that there is a need to bring them to public attention, and that there are really some things that need to be exposed.

What happened was that a large number of tobacco control practitioners (including many colleagues) began imploring me not to express my opinions about the tactics, actions, statements, and agenda of the movement publicly. I was instructed that it was acceptable to complain (i.e., "whine") internally, directly with the relevant groups, but that it was not acceptable or appropriate for me to share my opinions beyond the closed ranks of the tobacco control community.

The Rest of the Story

This reaction is one reason I now know that what I'm doing is needed. The very fact that my expressing my opinions to "outsiders" was viewed as so threatening to the movement convinced me that there must really be some terrible things going on that the movement doesn't want the public to find out about. If nothing inappropriate was going on, then there shouldn't have been any concerns.

This reaction always struck me as somewhat odd. After all, we are public health practitioners. I view myself and others in my profession as public servants. It is the public that we are trying to serve. How could it be somehow inappropriate to preclude the public from being aware of what we are thinking and what we are doing. In fact, if anything, my impression was that we should actually be inviting the public more into the discussion.

I don't view public health as something that we do "to" the public, but as something that we do "with" the public.

In fact, as I have discussed previously on this blog, public health ethical standards clearly indicate that our deliberations about potential public health interventions and policies should be transparent to the public - we should be willing to provide the public with information about the policies we are considering and the factors that are going into our decisions. So if I feel that the science behind our policies or actions are questionable, or that interventions we are proposing our inappropriate or unjustified, isn't it reasonable, if not my responsibility, to share these concerns publicly?

I remember vividly an email I received from a colleague shortly after my post in which I suggested that Americans for Nonsmokers' Rights (ANR) had misled the public by claiming that Associate Attorney General Robert McCallum was a former tobacco industry lawyer. The note chastised me for having expressed this opinion publicly, rather then simply having shared my thoughts with ANR itself (something which I had already done, but to no avail, except to get balled out by them).

Of most interest to me was the fact that the note did not take any issue with my contention that ANR had misled the public. Apparently, that wasn't the issue of concern. The issue of concern was that I had "betrayed" the tobacco control "inner circle" by expressing a criticism of our actions to the public.

Well I believe that the public is a pretty good judge and people should be able to judge for themselves. If ANR's actions were appropriate, then the public could read my commentary, disagree, and think that ANR was correct in its public attack on McCallum and that my argument was not particularly compelling. If there was no harm done, then there should have been nothing to fear.

What I began to realize is that there was harm done, and tobacco control groups knew it. They were worried about the public finding out about it, it became clear to me, specifically because there was something that they preferred to keep hidden.

I didn't come to this realization right away. My first thought, from the very beginning, was that if I just brought these issues to the attention of the relevant organizations, they would simply correct the problems. But my experience did not bear that out. For no less than two years, I went along with this approach, keeping my thoughts confined to the internal tobacco control community and relaying my concerns to the relevant organizations. To my dismay, I received not a single positive response. Instead, what I received were personal attacks and attempts to discredit me and defame my character and reputation and harm my career.

Believe me: if I had seen any response by organizations to my internal pleas, I would never have needed to even initiate this blog. The anti-smoking groups were eagerly anxious for me to share my concerns with them, but completely uninterested in doing anything about those concerns.

So I had two choices: keep my thoughts to myself or share them.

Frankly, it was really all the admonitions and pleadings to keep quiet that convinced me that there really was a "rest" of the story to be told - that I was really on to something.

In retrospect, I realize that entreating me to keep quiet and keep it all to myself and attacking me for betraying the movement and being "un-collegial" by sharing my opinions with the public who we are supposed to be serving was simply a technique to try to silence me and to quell the dissent that was becoming apparent inside the movement.

I think the silencers and quellers would have a more compelling point if one - even one - organization had changed its misleading communication about the acute cardiovascular effects of secondhand smoke. Out of a sample of more than 80 groups, if even one had responded to the concerns I expressed about misleading the public, then the dissent terminators might have had a point. Perhaps it could have been true that what was going on was simply careless mistakes by anti-smoking groups in their reporting of the science, and they would be thrilled to have the corrected information so that they could fix their web sites. It could have been true.

Thursday, June 29, 2006

It is quite clear that in communicating the findings of the new Surgeon General's report on secondhand smoke, the over-riding message to the public was that even small amounts of secondhand smoke exposure are harmful.

The first line of the press release announcing the release of the report stated: "U.S. Surgeon General Richard H. Carmona today issued a comprehensive scientific report which concludes that there is no risk-free level of exposure to secondhand smoke." It goes on to emphasize that"even brief secondhand smoke exposure can cause immediate harm."

One of the four major conclusions of the report highlighted in the Surgeon General's press conference remarks was that: "There is NO risk-free level of secondhand smoke exposure... ." Later in his remarks, the Surgeon General emphasized that"Breathing secondhand smoke for even a short time can damage cells and set the cancer process in motion. Brief exposure can have immediate harmful effects on blood and blood vessels, potentially increasing the risk of a heart attack."

The fact sheet that accompanies the report is entitled: "There is No Risk-Free Level of Exposure to Secondhand Smoke" and goes on to emphasize that "The U.S. Surgeon General has concluded that breathing even a little secondhand smoke poses a risk to your health."

The first fact noted in the brochure that accompanied the report is that: "There is no safe amount of secondhand smoke. Breathing even a little secondhand smoke can be dangerous."

And the Jim Lehrer interview transcript clearly picked up on this theme, as it was entitled "Surgeon General Concludes There is No Safe Level of Second-Hand Smoke."

The Rest of the Story

There are a number of reasons why I'm not so sure that the publicity focus on the absence of any safe level of exposure to secondhand smoke is entirely appropriate and effective as a public health message.

First, the message is not particularly meaningful. One can say that there is no safe level of exposure to any carcinogen. There is no safe level of exposure to car exhaust. There is no safe level of exposure to the sun's rays. There is no safe level of exposure to X-rays. There is no safe level of exposure to the benzene that is found in some sodas. There is no safe level of exposure to radon in homes. There is no safe level of exposure to arsenic that is found in many people's drinking water.

For that matter, there is no safe speed at which you can drive a car without risk of injury or death. There is no risk-free way to have sex with someone who has HIV infection. There is no safe method to travel from one place to another.

So stating that no amount of secondhand smoke is safe is not particularly meaningful. It also didn't take a 727-page detailed report to draw such a conclusion. We knew that already. It follows logically from the fact that secondhand smoke contains carcinogens. In fact, we have known that no amount of secondhand smoke is safe since at least 1961, when a Philip Morris internal report detailed the many carcinogens and toxins in tobacco smoke.

Second, this emphasis on the hazards of minute levels of, and brief exposures to, secondhand smoke seems to belie the importance that the public must place on assessing the dose of secondhand smoke in making decisions about their potential health risk. Dose consists both of the concentration of the smoke and the duration of exposure, and both of these are important considerations that we want the public to be aware of. Don't we?

Maybe I'm wrong, but isn't it more useful and informative to provide the public with a sense of the relative levels of exposure to secondhand smoke in different environments and situations then to scare the public into simply thinking that any exposure is terrible and that (perhaps) all exposures are equally bad? I think that it is important for the public to have some appreciation of the strong and important relationship between dose and risk. And I'm afraid that the overwhelming emphasis on there being no risk-free level of smoke exposure may obscure the importance of the dose-risk relationship.

Failing to emphasize the dose-risk relationship could have negative public health consequences, both from an individual and a policy perspective. From an individual perspective, is it not possible that some people will conclude that since any secondhand smoke exposure is putting them at risk, it doesn't make sense to reduce their exposure if they cannot eliminate it. In other words, for people who cannot avoid some exposure to secondhand smoke, is there any incentive for them to reduce their exposure if they are repeatedly hammered over the head with the idea that their limited smoke exposure is going to kill them anyway?

And for smokers, what incentive is there for them to cut down on their smoking if it is true that even brief exposure to secondhand smoke may cause them to have a heart attack anyway? If you're going to have a heart attack one way or another, why not continue to smoke and at least enjoy yourself before you keel over?

And the Surgeon General implied to the public that children who are exposed to secondhand smoke are going to eventually develop heart disease and cancer. What he said was: "We have evidence now that every day a child is exposed to secondhand smoke, they have higher incidence of asthma. Eventually, they'll develop cardiovascular disease and cancers over time."

The point is that by making secondhand smoke exposure sound so bad, such that even a tiny and brief exposure is hazardous and such that if you are exposed you are doomed to disease, aren't we taking away an incentive for people who cannot eliminate their exposure entirely to reduce it? Are we not taking away an incentive for smokers to quit smoking if they know that they will still hang out in the same smoky bars and be exposed to secondhand smoke. What's the point of their quitting smoking if the secondhand smoke in these bars is going to kill them anyway and there is no perceived benefit of reducing the level of their exposure?

Frankly, I think the people who are going to be hurt by this report are smokers. While for the most part, nonsmokers will be scared by this news and will largely become more vigilant and more aggressive in their attempts to avoid the smoke, many smokers may be alienated by the suggestion that even a few whiffs of secondhand smoke could kill them. There doesn't seem to be any point in quitting smoking by that logic.

This kind of reminds me of the mistake that public health advocates made in telling gay men in San Francisco that the only way to prevent AIDS was to use a condom every time. For some men, that is not a reasonable or possible dictate. It's not going to happen. But if that man believes that even one time without a condom is going to cause him to get AIDS, what incentive is there for him to make efforts to increase the frequency of condom use, especially when that one time has already occurred?

From a public policy perspective, I'm afraid that the Surgeon General's report is basically going to be a green light to expand efforts to ban smoking outdoors in places where people can easily avoid exposure and that it may actually take the focus off of indoor workplaces with extremely high levels of secondhand smoke exposure, such as casinos and bars. And I think it may result in more of a focus on protecting people with transient, periodic exposure to secondhand smoke and further neglect of people who are exposed regularly.

In his interview with Jim Lehrer, Dr. Carmona kept emphasizing the need to eliminate smoke exposure everywhere - in "any place." He included privately owned cars, homes, recreation places, and workplaces, but did not specifically point out any particular venues where exposure tends to be extremely high. In fact, reading the publicity surrounding the report, the main emphasis seemed to be given to regulation of tobacco smoke exposure in homes, cars, recreation places, and outdoors. By focusing so much on "any" exposure to secondhand smoke, I think the publicity may actually take policy makers' attention away from where the real problem lies.

Third, by emphasizing that any brief exposure to secondhand smoke can cause lung cancer, I believe this publicity may well harm efforts to search for the other causes of lung cancer among nonsmokers. Since I've devoted my career to the role of secondhand smoke in causing lung cancer among nonsmokers, I obviously think this is a critical issue, but by giving people the impression that any nonsmoker who gets lung cancer may well have gotten it from secondhand smoke, even if their exposure was minimal, are we not doing a potential disservice to the search for other causes of non-smoking-related lung cancer?

Fourth, when you give a message like this one - everyone is at risk - do you not undermine efforts to try to reach people who really are at the most risk? By scaring everyone in the population into thinking that they are at risk of disease from secondhand smoke, are we not taking attention away, perhaps, from the groups that are at the highest risk because of the highest levels of exposure? And might not these groups be less likely to take action to protect themselves than if the message was that certain groups are at particularly high risk and need to be protected urgently?

In some ways, this approach is really a cop out. Instead of having the acumen to examine risk levels and set priorities in policy making and intervention, you are basically just throwing up your hands and saying: "Everyone is at risk. Everyone needs to avoid secondhand smoke. Everyone - just don't do it!"

Rather than being a call for specific and prioritized actions to prevent disease in the most effective and efficient manner possible, it seems that the publicity put out by the Surgeon General's office is more of just a general public scare, devoid of any priorities, focus, or policy or intervention directives. It appears more like a vague warning of "Fire," rather then a clear directive like "Fire at 12 Main Street. Evacuate 12 Main Street, and then 8 and 10 Main Street." You don't want to go on television to tell people that there is a fire at 12 Main Street and everyone is potentially at risk. You want to first evacuate those buildings. We need to have some sense of direction and priorities in public health, and they should be based on a rational assessment of levels of risk. And that means that you have to evaluate and consider dose.

In some ways, I believe that the basic message here - everyone is at risk and the dose doesn't matter; no matter how small the dose, you are still at risk - may be a counter-productive one. Or at least it may undermine some of the very important findings of the Surgeon General's report. The report reviewed, for example, the levels of secondhand smoke exposure among different population groups and came to some conclusions that should guide policy makers. But those conclusions are completely obscured by the all-out emphasis on the absence of any safe level of exposure.

Before I close, it is worth noting that I am not offering as a reason why the message - there is no safe level - may be inappropriate is that it is incorrect. I am not suggesting that this message is inaccurate (unlike the claim that a brief exposure can cause heart disease or lung cancer). Of course there is no safe level. There is almost nothing that is completely safe. And especially not exposure to a bunch of carcinogens.

It seems odd to me that the tobacco control field is the only one where we seem adamant on emphasizing the concept of no safe level of exposure (with the possible exception of the "you have to use a condom every time" advocates). I'm not sure what the point is. Perhaps it's to scare people into avoiding smoke. And maybe that's a good thing. But perhaps, instead, the effect will be to obscure intervention and policy priorities. And to pit nonsmokers against smokers more vehemently. And to allow the anti-smoking movement to shift its attention from workplaces to the great outdoors, and then to cars and homes. And to discourage smokers from quitting.

The misrepresentation by the Surgeon General's office of the science of the acute cardiovascular and carcinogenic effects of a brief exposure to secondhand smoke suggests to me that there is a dire need for more open discussion of scientific issues within the tobacco control community.

This misrepresentation of the heart disease risk attributable to a brief secondhand smoke exposure comes many months after I began to gradually reveal more than 80 anti-smoking groups making similar claims, explained why I view these claims as misleading, and attempted to initiate, within the movement, a discussion about the scientific validity of these assertions.

Unfortunately, rather than engaging in a discussion of the scientific issues, the tobacco control list-serves on which I had begun to communicate my concerns to thousands of scientists and advocates decided to throw me out and to stifle any further discussion. Actually, that's misleading. There was no discussion to begin with. The response I engendered was not arguments about the validity of my reasoning; it was personal attacks about my honesty, character, and funding. But my expulsion from the movement's communication infrastructure did stifle any possible future discussion of these issues; I'm confident that with time, advocates' defensive reactions would eventually have given way to a serious consideration of the scientific issues at hand.

By taking this issue off the table for discussion, it made it impossible for the Surgeon General's office to become aware of the importance of carefully considering the differences between the physiologic phenomena of transient changes in endothelial function, platelet activation, lipid metabolism, artery elasticity, and cardiac autonomic tone that follow a brief secondhand smoke exposure and the actual risk of developing heart disease or suffering a heart attack due to that brief exposure.

The lesson here, for me, is that the tobacco control movement needs to find ways of opening up scientific and policy discussion, rather than closing it off. The movement needs to find ways of making individuals more comfortable to share their opinions about our agenda, our tactics, our actions, and our public statements, not to create an atmosphere where people are afraid to speak out lest their careers be threatened or destroyed.

Only a major change in the way in which the movement operates will allow this problem to be corrected so that it does not recur in the future. But that change is not so radical - what it simply requires is a willingness to consider alternative viewpoints and to address arguments on their merits. It's time to drop the defensive posturing that treats any criticism of the anti-smoking movement as a heretical violation of some sacred code and elicits an offensive attack on the perpetrator of this heinous crime of dissent. Tolerating dissent and taking the time to consider the opinions of others, even if those opinions challenge the prevailing dogma, can only help the movement in the long run. And it could probably prevent the massive misleading of the public that occurred yesterday.

According to an article in the Contra Costa Times, a California state Senate committee yesterday approved a bill that would ban smoking in cars with children under age 6 present. The bill makes smoking in a car with young children a primary offense, meaning that the police can pull a car over for this infraction. The first violation would result in a warning and subsequent violations would yield $100 tickets. Parked cars or cars located on private property would be included.

Senator Deborah Ortiz, chair of the Senate Health Committee (which approved the bill) defended the legislation by arguing that smoking around young children is a form of child abuse: "There's no excuse in today's society for any mother of any age, or any level of education, to do something which I consider akin to child abuse."

The Rest of the Story

I think one really has to question whether coercion is the appropriate public health intervention approach to dealing with the problem of parents smoking around their children. This is one case where I think that education and persuasion are appropriate approaches, but coercion is not.

This issue also raises important concerns about the limits of government intrusion into personal privacy and autonomy.

If California legislators ban smoking in cars with children present, then I simply cannot see any justification for failing to ban smoking in homes with children.

I do not see any real difference between one's own car and one's own home when it comes to regulating smoking to protect the health of children. If anything, I would argue that the threat to children from smoking in the home far outweighs the threat from smoking in cars, because although the concentration of secondhand smoke in cars is likely to be higher, the length of exposure in homes is likely to be substantially higher. Moreover, both the overall prevalence and overall time of exposure for children is almost certainly higher in the home than in cars. Many families do not even own a car, but nearly every family lives in some sort of home.

In other words, secondhand smoke exposure in the home is almost certainly a greater public health hazard for young children than secondhand smoke exposure in cars.

So if one is going to support legislation to ban smoking in cars with children, I simply do not see how one cannot also support legislation to ban smoking in homes with children. There is no qualitative difference that I can see between the two, and the quantitative difference would argue for a greater priority on the problem of exposure to secondhand smoke in the home.

Both are examples of the government intervening to protect children from risk of illness or disease due to lawful behaviors of their parents in the privacy of property that they personally own and are not used for business or commercial or any public purposes.

Both involve infringing upon parents' authority to make their own decisions about behaviors that potentially affect the health of their children.

As much as I hate to see children exposed to secondhand smoke in the home because of the potential health hazards, I simply believe that the privacy rights in the home outweigh the government's interest in regulating a lawful behavior that is merely a potential threat

Regulating smoking in the home would open the door to a wide range of intrusions into personal privacy that people would, I think, find highly objectionable. I don't think we want to see regulations that require what parents must or must not feed their kids, how much physical activity their children must have, what their kids can or cannot watch on television, what movies children can watch, or whether or not parents are required to put sunscreen on their children when they go outside to play for an hour.

I therefore view regulation of smoking in cars similarly. I think the intrusion into individual privacy of behavior on their own property outweighs the government's interest in protecting the health of children from this potential health hazard.

So while the issue under discussion may appear to simply be smoking in cars, what is at stake here is something far more significant: what the California legislature is really going to decide in the coming weeks is whether or not the government will step in to regulate smoking in the home, something which for decades, anti-smoking groups have considered to be off limits for our legislative advocacy efforts.

What concerns me is that according to the article, a number of anti-smoking and public health organizations are supporting this legislation. This indicates to me that these organizations would support a ban on smoking in the home.

I don't believe that this battle is going to end in cars. I think that, buoyed by the Surgeon General's alarming warning about the effects of even brief exposure to secondhand smoke, the anti-smoking and public health groups are going to aim directly for the home.

Wednesday, June 28, 2006

Apparently, the actual conclusions of a comprehensive 727-page report which documents all kinds of adverse health effects of secondhand smoke were not sensational enough for the Surgeon General's office. In what seems to be a contagious phenomenon which has now infiltrated a federal tobacco control organization, public health groups that report the science of secondhand smoke do not seem able to accurately report the science to the public.

Rather than sticking to the carefully-reviewed science in the detailed and thorough report, the press release and other related communications of the Surgeon General regarding the findings of his report were sensationalized in a way that makes these communications quite misleading.

The report documents an increased risk of heart disease and lung cancer among nonsmokers who are chronically exposed to high levels of secondhand smoke. However, instead of simply reporting that finding to the public, the Surgeon General distorted the science to communicate to the public that brief exposure to secondhand smoke can increase heart disease and cancer risk.

Here is what the Surgeon General's report concluded regarding the effects of secondhand smoke exposure on heart disease and lung cancer:

"The evidence is sufficient to infer a causal relationship between secondhand smoke exposure and lung cancer among lifetime nonsmokers. ... The pooled evidence indicates a 20 to 30 percent increase in the risk of lung cancer from secondhand smoke exposure associated with living with a smoker. ... The evidence is sufficient to infer a causal relationship between exposure to secondhand smoke and increased risks of coronary heart disease morbidity and mortality among both men and women."

"Even brief exposure to secondhand smoke has immediate adverse effects on the cardiovascular system and increases risk for heart disease and lung cancer, the report says."

And here is what the Surgeon General stated in his remarks to the media:

"Breathing secondhand smoke for even a short time can damage cells and set the cancer process in motion. Brief exposure can have immediate harmful effects on blood and blood vessels, potentially increasing the risk of a heart attack."

Here is what the Surgeon General stated in an accompanying fact sheet:

"Breathing secondhand smoke for even a short time can have immediate adverse effects on the cardiovascular system, interfering with the normal functioning of the heart, blood, and vascular systems in ways that increase the risk of heart attack."

And here is what the Surgeon General says in an accompanying brochure:

"Even a short time in a smoky room causes your blood platelets to stick together. Secondhand smoke also damages the lining of your blood vessels. In your heart, these bad changes can cause a deadly heart attack."

The Rest of the Story

The rest of the story is that the Surgeon General's press release distorts the science presented in the report and ends up presenting misleading and inaccurate information to the public.

The press release claims that a significant finding of the Surgeon General's report is that: "Even brief exposure to secondhand smoke has immediate adverse effects on the cardiovascular system and increases risk for heart disease and lung cancer."

To re-phrase this for clarity, the Surgeon General is publicly claiming that brief exposure to secondhand smoke increases risk for heart disease and lung cancer.

But there is absolutely no evidence to support this claim. Certainly, no evidence is presented in the Surgeon General's report to support this claim. And certainly, the Surgeon General's report draws no such conclusion.

In fact, such a conclusion flies in the face of common medical sense. How could it possibly be that a brief exposure to secondhand smoke can cause heart disease? It takes many years for heart disease to develop. It takes years of exposure to tobacco smoke even for a smoker to develop heart disease. I estimate that it takes at least 25 years of exposure (based on the fact that very few smokers are diagnosed with heart disease before age 40).

So how could it possibly be that for an active smoker, heart disease takes 25 years of exposure to tobacco smoke to develop, but for a passive smoker, it only takes a single, transient, brief exposure?

It is also quite misleading to tell the public that a brief exposure to secondhand smoke increases the risk of lung cancer. There is certainly no evidence for this and the Surgeon General's report itself draws no such conclusion. In fact, the report makes it clear that most of the studies linking secondhand smoke and lung cancer studied nonsmokers with many years of intense exposure.

The other claims made by the Surgeon General are also quite misleading, although perhaps not as absurdly inaccurate."Breathing secondhand smoke for even a short time can damage cells and set the cancer process in motion. Brief exposure can have immediate harmful effects on blood and blood vessels, potentially increasing the risk of a heart attack."

This statement is misleading because it implies that a brief exposure to secondhand smoke can cause cancer (by setting the cancer process in motion). There is simply no evidence to support such a claim, and no such evidence is presented in the Surgeon General's report. More importantly, there is no evidence that brief exposure increases the risk of a heart attack and the Surgeon General's report offers no evidence to this effect, nor does it conclude that brief secondhand smoke exposure does increase heart attack risk. This is pure speculation, unsupported by any compelling scientific evidence.

"Breathing secondhand smoke for even a short time can have immediate adverse effects on the cardiovascular system, interfering with the normal functioning of the heart, blood, and vascular systems in ways that increase the risk of heart attack."

Again, while there certainly is evidence presented in the report that brief secondhand smoke exposure interferes with the "normal" functioning of the heart, blood, and vascular systems, there is no evidence that these changes acutely increase the risk of a heart attack. Moreover, even if one relied on pure speculation, rather than on science, one would have to clarify one's claim by specifying that it only referred to individuals with pre-existing severe coronary artery disease, something which the Surgeon General does not do here.

"Even a short time in a smoky room causes your blood platelets to stick together. Secondhand smoke also damages the lining of your blood vessels. In your heart, these bad changes can cause a deadly heart attack."

Once again, this is pure speculation, not based on any scientific evidence. There is no conclusion in the Surgeon General's report that brief exposure to secondhand smoke causes fatal heart attacks, as claimed here. There is no evidence presented in the report which documents any increased fatal heart attack risk associated with a brief exposure to secondhand smoke. And even pure speculation would require one to clarify this claim to refer only to individuals with severe existing coronary artery disease.

I need to make it clear that none of these misleading and inaccurate scientific claims are made in the Surgeon General's report. What appears to be going on here is very similar to the "20-minute" and "30-minute" claims about which I have written extensively: the science is simply being distorted to sensationalize the findings, resulting in assertions that are misleading, inaccurate, absurd, unsupported by scientific evidence, and inconsistent with the findings of the report itself.

It appears to me that tobacco control organizations of all kinds and at every level are simply unable to accurately and honestly communicate the science of secondhand smoke to the public. For some reason, there appears to be a need to distort the science in an effort to sensationalize it and increase the emotional impact of the communication. The end result is to produce public claims that are inaccurate and which mislead the public.

Now I hope that readers can see why I wrote, even before this report and its accompanying materials were released, that the report would not matter. It turns out that I was correct. It really didn't matter. Apparently, the Surgeon General was going to say whatever he wanted about the acute health effects of secondhand smoke and not let the actual conclusions of the report get in the way.

It didn't matter that the report failed to conclude that there was any heart attack risk associated with brief exposure to secondhand smoke. The conclusion, widely disseminated to the public, was that a brief exposure to secondhand smoke increases heart disease risk and causes heart attacks.

The 727-page document was not necessary to make that claim. More than 80 anti-smoking groups were already making this fallacious claim and since it was and remains unsupported by scientific evidence, it really didn't matter that the comprehensive review of the scientific evidence did not support such a conclusion. The science was simply not going to get in the way of the tobacco control movement's ability to disseminate this sensationalized (and untruthful) claim.

It is important to understand that while the Surgeon General's report itself underwent rigorous scientific review, and thus does not make any outlandish claims, the communications put out by the Surgeon General reporting the findings of the report did not undergo independent scientific review. And it really shows. The difference between the press release and related communications and the Surgeon General's report itself are striking.

In fact, after reading the press release, I was fully expecting to find in the report some conclusions and supporting documentation related to an acute heart attack risk and increased lung cancer risk associated with brief secondhand smoke exposure. I was shocked to find that there was no mention of such a relationship; no conclusions, no documentation. Instead, the report appropriately presented the scientific evidence of acute effects of secondhand smoke on vascular function as supporting the biologic plausibility of the observed effects of chronic exposure on heart disease. There was no suggestion in the report that a brief exposure does or even could increase heart disease risk. Nor was there any suggestion (much less scientific evidence) that a brief exposure is enough to cause lung cancer.

Unfortunately, I'm forced to reach the conclusion that tobacco control organizations are simply unable to accurately communicate secondhand smoke science to the public. They are widely distorting the science to create a more sensational and emotional impact on the public. When this phenomenon goes all the way up to the level of the Surgeon General's office, you know you've got a serious scientific integrity problem.

What has gone wrong?

I worked for two years at the Centers for Disease Control and Prevention, in the Office on Smoking and Health, which is the office that usually leads the review of the Surgeon General's report. So I'm quite familiar with the level of scrutiny that is usually applied to any communications by the Surgeon General, but especially with regards to what is viewed as the rather "controversial" issue of secondhand smoke.

We remained highly vigilant and very careful about our public communications about the effects of tobacco smoke and those of the Department of Health and Human Services, because there was a huge perceived tobacco industry presence that would scrutinize our claims and call us to task if there were any inaccuracies, even if they were slight and not particularly meaningful.

But now, with the tobacco companies having largely abandoned this "oversight" role and playing a back-seat role (their main comment on the report was something to the effect of "We haven't fully reviewed it yet"), there is apparently nothing to stop us from making just about any claims that we want to make.

So if we want to impress the public with the magnitude of the secondhand smoke hazard by trying to convince them that even a brief exposure can cause heart disease and lung cancer, so be it. The tobacco industry is not going to get in our way any more. Why should the science?

NOTE: Since a large number of readers of this post are likely not to be regular readers of this blog, I want to make it clear that I agree with most of the conclusions of the Surgeon General's report itself and that I certainly (and have for many years) believed that chronic secondhand smoke exposure is a cause of heart disease and lung cancer. I believe that the conclusions of the Surgeon General's report are sufficient to justify smoke-free workplace laws. But I think that the truth is enough. I don't see why we need to distort and sensationalize the science in order to increase the impact of these findings and attempt to advance the agenda. In my view, it greatly harms public health by threatening the very credibility of tobacco control and public health practitioners and organizations. In the long run, this is going to harm the public health cause more than any fleeting publicity gains to be obtained from trying to convince people that breathing drifting tobacco smoke for a half hour is going to cause you to have a heart attack, develop atherosclerosis, or come down with lung cancer 30 years later.

An article in today's Cleveland Plain Dealer highlights my concerns about the fallacious claims that one anti-smoking group - SmokeFreeOhio - is making about the acute cardiovascular health effects of secondhand smoke.

According to the article: "Dr. Michael Siegel, a professor of social and behavioral sciences at the Boston University School of Public Health, accuses the health group SmokeFree Ohio of touting bogus scientific data in its campaign for a statewide ban on public indoor smoking on the November ballot.

An item that Siegel posted Thursday on his blog (tobaccoanalysis.blogspot.com) takes issue with several claims about the dangers of secondhand smoke. SmokeFree Ohio, a campaign of the American Cancer Society, has stated on its Web site that 20 minutes of exposure elevates risk of heart attack and that 30 minutes of exposure can cause narrowing of blood vessels, contributing to hardening of the arteries. ...

The statements 'are so wildly misleading and inaccurate that they completely fly in the face of pure common sense,' Siegel wrote. ...

Tracy Sabetta of SmokeFree Ohio said the information cited by the group comes from the American Heart Association and the federal Centers for Disease Control and Prevention. ... Her organization stands by the statements, she said.

'I don't come up with any number of my own,' she said. 'I only report numbers from credible sources.'"

The Rest of the Story

There's just one problem with SmokeFreeOhio's defense of its claims: nowhere does the CDC (or the American Heart Association for that matter) state that 30 minutes of secondhand smoke exposure can cause narrowing of the arteries and hardening of the arteries (atherosclerosis) and nowhere does CDC state that 20 minutes of secondhand smoke exposure reduces the ability of the heart to pump, thereby putting a nonsmoker at an increased heart attack risk.

Actually, I think that SmokeFreeOhio is on even less acceptable ground now than it was before. If it were simply misinterpreting the data itself, then one could argue that it was a simple misinterpretation of the data.

But now, since it insists that it is merely copying a claim from the CDC, it becomes clear that SmokeFreeOhio is intentionally misleading the public, because there is no such claim that CDC made.

Where, I would ask, does CDC claim that 30 minutes of exposure to secondhand smoke causes "narrowing of blood vessels, restricting the flow of blood and contributing to hardening of the arteries?"

Where does CDC claim that 30 minutes of exposure boost your risk of building up fat deposits in such a way that it could "lead to heart attacks and strokes?"

Where does CDC claim that 2 hours of secondhand smoke exposure increases the risk of "an irregular heart beat that can itself be fatal or trigger a heart attack?"

And where does CDC claim that 20 minutes of secondhand smoke exposure reduces "the ability of the heart to pump?"

The truth is that the CDC makes no such claims.

SmokeFreeOhio cannot dismiss my challenge to its scientific integrity by throwing it off on CDC. Because CDC didn't make the claims - SmokeFreeOhio did.

Interestingly, the American Heart Association statement that SmokeFreeOhio states it is using as the basis of these claims makes no such assertions. It simply points out that chronic exposure to secondhand smoke may cause atherosclerosis, a fact that is not relevant to this discussion of the acute effects of a brief exposure to secondhand smoke.

The rest of the story is that SmokeFreeOhio is truly misleading the public about the acute cardiovascular effects of secondhand smoke, and they are apparently doing it intentionally, at least in my opinion. It is clear that they are not drawing on their own expertise to make these scientific judgments; they are simply relying on the statements of other groups. Thus, they must be able to produce the statements these other groups have made which back up their assertions. But they can't, because such statements don't exist. This amounts to what I see as a conscious and intentional attempt to mislead the public by sensationalizing the acute health effects of secondhand smoke.

It's one thing to take a controversial position and stand up for what you are saying. But it's another to attribute what you're saying to someone else, when that someone else never made such a statement. SmokeFreeOhio is apparently trying to hide behind a curtain. They are afraid to deal with the actual science. Rather then simply admit a mistake, they are attempting to mislead the public yet again by making us think that the CDC made these ridiculous claims.

Now, what SmokeFreeOhio is doing isn't just misleading and inaccurate; it's unethical.

Tuesday, June 27, 2006

Despite containing more than 727 pages of extensive review of nearly every possible health manifestation of exposure to secondhand smoke, the Surgeon General's report released today does not conclude that there is any severe or fatal cardiovascular impact of a single acute (i.e. 30 minute) exposure to secondhand smoke, as currently claimed by more than 80 anti-smoking groups.

The report does review the scientific literature regarding the acute cardiovascular effects of secondhand smoke. It reviews studies of the effects of brief secondhand smoke exposures (from 5 minutes to 2 hours) on artery elasticity, endothelial function, platelet activation, lipid metabolism, and heart rate variability. It finds that these brief exposures cause changes in platelet and vascular function that may be as large as those observed in active smokers.

However, it appropriately uses these data to conclude that this scientific literature provides biologic plausibility of a relationship between chronic secondhand smoke exposure and heart disease and to provide a plausible reason why the observed relationship between the dose of tobacco smoke (active vs. passive smoking) and the clinical effect (heart disease) is not linear.

Unlike what a large number of anti-smoking groups are doing, the Surgeon General's report does not use these data to suggest to the public that a short exposure to secondhand smoke can therefore cause atherosclerosis, clogged arteries, blood clots in arteries, narrowed arteries, cardiac arrhythmias, heart attacks, and death.

Instead, the report concludes that: "findings of a wide variety of clinical and experimental studies of various designs demonstrate that the effects of secondhand smoke on the cardiovascular system occur at low doses in nonsmokers, with some of the effects (on platelets and vascular function) similar to those in active smokers. For this reason, it is not appropriate to scale from the effects of active smoking in a linear, dose-dependent approach to estimate the effects of exposure to secondhand smoke based on comparative doses of smoke components (Howard and Thun 1999). Secondhand smoke interferes with the normal functioning of the heart, blood, and vascular systems in ways that increase the risk of a cardiac event. For some of these effects (changes in platelet and vascular function), the immediate effects of even short exposures to secondhand smoke appear to be as large as those seen in association with active smoking of one pack of cigarettes a day. Some evidence indicates lower levels of circulating antioxidants associated with secondhand smoke exposure. The experimental and observational evidence reviewed in this chapter supports the plausibility of the findings of the epidemiologic studies reviewed in Chapter 8 (Cardiovascular Diseases from Exposure to Secondhand Smoke). The large body of evidence documenting that secondhand smoke produces substantial and rapid effects on the cardiovascular system demonstrates that even a brief exposure to secondhand smoke has adverse consequences for the heart, blood, and blood vessels...".

It is important to note that the adverse consequences being referred to here on the heart, blood, and blood vessels include decreased artery elasticity, endothelial dysfunction, platelet activation, impaired lipid metabolism, and decrease in heart rate variability. They do not refer to hardening of the arteries, blood clots, clogged arteries, impaired coronary artery blood flow, heart attacks, catastrophic arrhythmias, or death.

Interestingly, while a large number of anti-smoking groups are claiming that acute exposure to secondhand smoke causes atherosclerosis, the report does not even conclude that chronic exposure to secondhand smoke causes hardening of the arteries (atherosclerosis). Instead, the report concludes that there is suggestive evidence, but that it is premature to draw definitive conclusions: "Studies of secondhand smoke and subclinical vascular disease, particularly carotid arterial wall thickening, are suggestive but not sufficient to infer a causal relationship between exposure to secondhand smoke and atherosclerosis."

The Rest of the Story

I think it is now time for the 80+ anti-smoking groups that have made or are making the fallacious scientific claim that 30 minutes of exposure to secondhand smoke represents a severe and potentially fatal cardiovascular risk for the population of nonsmokers retract or correct their claims.

If a 727-page, comprehensive report that provides an in-depth and exhaustive review of the health effects of secondhand smoke fails to conclude that there is any risk of atherosclerosis, heart disease, heart attacks, or heart disease-related death from a brief exposure to secondhand smoke, then I think these groups do not have a leg to stand on in continuing to disseminate their fallacious claims.

And if the report does not even conclude that chronic exposure to secondhand smoke causes hardening of the arteries, it is hard to justify telling the public that just 30 minutes of exposure to secondhand smoke causes hardening of the arteries.

It has become clear that these claims are not supported by the evidence, and given the high visibility of the Surgeon General's report, the anti-smoking groups are now certainly aware of this. Thus, any prolonged delay in retracting or correcting these claims can only be interpreted as suggesting that the anti-smoking groups have no sincere interest in reporting and communicating the truth.

The Rest of the Story will be following the status of these fallacious claims over the next week, and reporting on any retractions or changes that are made. Given the failure of the Surgeon General's report to provide any support for the claims being made by anti-smoking groups, I think it is not unreasonable to expect that most, if not all, of these fallacious claims should and will be retracted over the course of the next week.

The Omaha World-Heraldreported yesterday that just 30 minutes of secondhand smoke increases a nonsmoker's risk of developing blood clots in his or her arteries. According to the article: "Within a half-hour, the platelets in a person's blood vessels become stickier, increasing the likelihood of clots...".

It's not clear exactly where this information came from, but it's a good bet that it originated from one of the 80+ anti-smoking groups which are claiming that just a half-hour (or less) of exposure to secondhand smoke causes hardening of the arteries, clogged arteries, blood clots in arteries, catastrophic arrhythmias, heart attacks, and death.

The World-Herald also reported that: "For at least eight hours after leaving a smoky bar, the effects remain in the blood system - with the contaminants themselves remaining much longer."

The Rest of the Story

On the day that a new Surgeon General's report will be released which focuses on the health effects of secondhand smoke, it's not clear to me why we need a new Surgeon General's report.

If anti-smoking groups are already spreading word that just 30 minutes of secondhand smoke causes clotting of the arteries and can kill you, then it seems to me that we really don't need a detailed scientific report on the actual, documented effects of secondhand smoke.

Why does it really matter what the actual, documented effects are if anti-smoking groups are simply going to over-dramatize the situation and make up whatever alarming claims they want to? Let's face it. The 30-minute claim is a "made-up" claim; it is not based on scientific evidence:

There is no evidence that 30 minutes of secondhand smoke exposure causes hardening of the arteries.

There is no evidence that 30 minutes of secondhand smoke exposure causes reduced coronary blood flow.

There is no evidence that 30 minutes of secondhand smoke exposure causes narrowed or clogged arteries.

There is no evidence that 30 minutes of secondhand smoke exposure causes blood clots.

There is no evidence that 30 minutes of secondhand smoke exposure causes fatal or catastrophic cardiac arrhythmias.

There is no evidence that 30 minutes of secondhand smoke exposure causes heart attacks or death.

There is, in fact, no scientific evidence that a single 30 minute exposure to secondhand smoke poses any significant acute cardiovascular health threat to anyone other than someone who already has coronary artery disease.

But anti-smoking groups are widely going around making these claims, and the media are clearly picking up on this and reporting the fallacious claims to the public.

It's also not clear where the paper got the idea that the risk of suffering a blood clot in an artery from secondhand smoke lasts for 8 hours after leaving a smoky bar, but I'd bet that it came from an anti-smoking group which is attempting to sensationalize the health threat posed by acute secondhand smoke exposure in order to promote smoking bans.

The truth is that the effects of acute secondhand smoke exposure on aortic elasticity reversed completely within 15 minutes of discontinuation of exposure. So it's misleading to suggest that the "artery-stiffening" effect of secondhand smoke lasts for 8 hours. Even the platelet-aggregatory effects of secondhand smoke only lasted for 6 hours, so it's not clear where the 8 hour figure comes from. But since the alleged risk of suffering a blood clot from 30 minutes of secondhand smoke is not a documented one, I guess it doesn't really matter how long one claims that "effect" lasts.

While we all await the release, later today, of the Surgeon General's report on the health effects of secondhand smoke, I am less than convinced that the report has any significance. If we're going to make up our health claims in order to sensationalize them, then who cares what the actual scientific evidence shows?

Friday, June 23, 2006

In a piece published Thursday in the Orlando Sentinel and many other national and international newspapers, columnist Kathleen Parker blasts the anti-smoking movement for invading into womens' privacy by attempting to regulate smoking by pregnant women (see my earlier posts - #1 and #2 on this Arkansas initiative).

Parker takes on the anti-smoking movement in sweeping fashion, calling us jihadists who, not satisfied with banning smoking in workplaces, are now crusading into people's cars, homes, and even into the womb:

"First they came for the workplace, then for people's homes and cars, and then the great outdoors. Now the anti-tobacco jihadists, having helped ban smoking in most public and many private places, have turned their attention to the most private space of all -- the womb. That very personal place where humans incubate could be the next battlefield between smokers and those who have never uttered the words: 'It's none of my beeswax.' This latest brainstorm comes from Arkansas, where Rep. Bob Mathis successfully shepherded legislation making it unlawful to smoke in cars in which small children are passengers. Apparently not satisfied with saving the recently born, Mathis wondered whether it would be constitutional to prohibit mothers from smoking while pregnant. Studies show, after all, that fetuses are at risk for low birth weight if their mothers smoke while pregnant. ... Already Banzhaf is setting his sights on fetal rights related to their smoking mums. While it is legally defensible to abort a fetus up until moments before birth, it is apparently inconceivable that a woman would expose her unborn child to the harmful effects of smoking. While you're struggling to wrap your mind around that nonsensical nugget, Banzhaf is already issuing press releases. In a recent one from the organization he heads, Action on Smoking and Health, Banzhaf predicts that prohibiting smoking by pregnant women would pass constitutional muster. ... Certainly life offers enough problems to keep government regulators and litigators indefinitely occupied, but one has to ask: Are smoking mothers worthy of our censure? What about pregnant women who drink? Or who refuse to take their vitamins? Or who listen to hip-hop when studies show that Bach makes you smarter? 'Sorry lady, but you're under arrest for dereliction of maternity duty.'"

Parker argues that we should not coerce people, through the arm of the law, to make wise decisions regarding personal health behaviors: "No one's suggesting that pregnant women should smoke, or drink, or pole-dance -- or whatever tempts the masses these days. But people have a right to be stupid, to make bad decisions, to marry the wrong guy, to eat the wrong foods and, alas, to elect the wrong people to public office."

She also notes that if one argues that legislating women's behavior during pregnancy is not being done in a paternalistic fashion, but to protect another human life (that of the fetus), then ASH is actually supporting the ultimate intrusion into womens' privacy - outlawing abortion: "In a final bit of irony, the move to prohibit smoking while pregnant would seem to lend strength to the argument that a fetus is a human being entitled to all the rights and privileges accorded personhood. Instead, it merely strengthens the case that government has no business regulating a woman's womb. Or any other body part."The Rest of the Story

This story demonstrates how anti-smoking groups like ASH, through their fanaticism, are harming the credibility and reputation of the entire tobacco control movement. These groups' efforts are legitimizing opponents' claims that we are indeed fanatical, overzealous crusaders rather than reasonable, evidence-based public health practitioners.

Often in the past, when I've seen columnists using this type of jargon about the anti-smoking movement (i.e., calling us extremists), it has been clear that the writer simply failed to appreciate what I saw as legitimate public health concerns. However, I have to admit that here, Parker seems to be quite on target with her commentary, and she in fact makes many of the same arguments that I offered in my own commentary in which I myself took issue with the initiative, supported by the anti-smoking movement, to ban smoking during pregnancy.

In their zeal to punish smokers and make their lives miserable, ASH and other anti-smoking groups are going to take all of us tobacco control practitioners down with them. Because no anti-smoking group is, or will speak out against this nonsense, the entire movement will come to be seen as pushing for this extreme invasion of individual privacy and autonomy. The credibility and reputation to be tarnished will be not merely that of ASH, but of the entire tobacco control movement.

Thursday, June 22, 2006

There appears to be a lot of smoke spewing around Ohio these days - and I'm not talking about the smoke coming from the Cinergy plant in New Richmond.

It's coming from the seemingly most unlikely of places: a public health group that is trying to fight the lies and deception of the tobacco industry and set the record straight about misleading communications to the public.

If you're trying to blast your opponents for using misleading public communications that deceive people about the facts, it's probably not too wise to be using the same tactic yourself.

But that's exactly what SmokeFreeOhio, a broad coalition of anti-smoking and public health groups in Ohio, is doing to promote a state initiative that would eliminate smoking in workplaces, including bars and restaurants.

On its web site, SmokeFreeOhio is claiming that 30 minutes of secondhand smoke exposure is enough to cause narrowing of blood vessels and hardening of the arteries, that just 30 minutes of secondhand smoke exposure is also enough to cause fat deposits that increase heart disease and stroke risk, that 2 hours of secondhand smoke exposure increase the risk of a catastrophic or fatal heart arrhythmia, and that just 20 minutes of secondhand smoke exposure reduces the ability of the heart to pump and thus puts a nonsmoker at increased risk of suffering a heart attack.

On March 21 of this year, exactly 3 months ago, I wrote to SmokeFreeOhio noting my concerns about the scientific inaccuracy of these statements and providing detailed reasoning, including scientific citations, for why I believed that these claims were fallacious (see text of letter below). The organization is clearly aware of who I am as well as my scientific qualifications to comment on this issue, and apparently thinks enough of my scientific abilities to cite my research findings and conclusions in the same fact sheet (reference 32).

However, to this day, the organization has not corrected, clarified, retracted, or otherwise altered its fallacious claims. Since a quarter of a year has gone by, I think it is not unreasonable to draw the conclusion that SmokeFreeOhio has no intention of fixing its inaccurate and misleading public claims and that the group either doesn't agree that these statements are inaccurate, agrees that they are inaccurate but doesn't care, agrees that they are inaccurate and does care, but is intentionally misleading the public in order to garner more support for the agenda it is promoting, or doesn't really care enough about my concern in the first place to review their public statements in any reasonable length of time.

The Rest of the Story

I have already explained, in some detail, why I believe that each of the 4 major statements above are fallacious, and I will not repeat that commentary here.

The important point is that these scientific claims are so wildly misleading and inaccurate that they completely fly in the face of pure common sense. It doesn't take a rocket cardiologist to understand that it takes more than 30 minutes for narrowing of the arteries to occur, and to such a degree that it restricts blood flow and contributes to hardening of the arteries. And there simply isn't any scientific support for any of these four claims. In fact, the scientific evidence demonstrates that these claims are untrue.

The second important point is that SmokeFreeOhio has now had 3 full months to review these statements and to correct or clarify them. This is not particularly complicated material and it shouldn't take 3 months to review. But allowing the benefit of the doubt, by now the claim should have been corrected if it was found to be misleading or inaccurate.

So we are left with the 4 possibilities, none of which are particularly attractive for the anti-smoking movement. Obviously, if the organization is intentionally misleading the public or doesn't care enough to correct the claim, then it isn't a pretty story. And if SmokeFreeOhio doesn't particularly care about these concerns, then it is a shame, because we in tobacco control should take pride in our scientific integrity, especially when we spend much of our time attacking others for their lack of such.

The final possibility, that the group has concluded that there is nothing wrong with these claims, may seem more benign, but unfortunately, if true, it would spell the end of the viability of the anti-smoking movement in my view. Because if we are unable to interpret science to any reasonably accurate extent, then we really have no business communicating science to the public. If we truly believe that 20 minutes of secondhand smoke impairs the heart's ability to pump, then why should we be trusted to make any statements about the effects of secondhand smoke?

These same comments apply, I'm sure, to many of the more than 80 organizations that have made similar claims. I'm not trying to suggest that SmokeFreeOhio is any worse than these other examples; it just happens to be the group with which I had the most direct communication, and so I'm absolutely sure that they are well aware of my concerns.

This story also illustrates why I have not spent countless hours of my time contacting the 80+ groups individually. The response I received from each of the few groups that I did contact was uniform: they did nothing.

Unless you're a fan of irony and hypocrisy, the rest of the story - that an anti-smoking group that is trying to convince the public that its opposition is blowing smoke but is blowing smoke itself - is not particularly pleasing.

It is only a question of time before the media picks up on this. Already, a letter to the editor appeared in the Athens News which called SmokeFreeOhio on the accuracy of its claims. The damage that is being done to SmokeFreeOhio's credibility is certainly important, but it's time for us to realize that the damage being done applies to all of us in tobacco control and public health.

Letter to SmokeFreeOhio (sent March 21, 2006)

Here are the specific statements on the fact sheet that I feel are inaccurate, and a brief description of my reasoning:

1. "After twenty minutes of exposure to secondhand smoke, a nonsmoker's blood platelets become as sticky as a smoker's, reducing the ability of the heart to pump and putting a nonsmoker at an elevated risk of heart attack."

I agree that there is evidence that after 20 minutes of secondhand smoke exposure, platelet aggregation increases and that it may increase to the level of that seen in an active smoker. Thus, it is fine to say that a nonsmoker's platelets become as sticky as a smoker's after 20 minutes of secondhand smoke exposure.

However, you can't make the jump from a little platelet stickiness to a reduced ability of the heart to pump and an elevated risk of heart attack. You can't equate a transient increase in platelet stickiness with an elevated heart attack risk. And you can't equate it with reducing the ability of the heart to pump.

If someone were exposed to secondhand smoke repeatedly for a long period of time, then the constant and prolonged effects of secondhand smoke on platelets, along with the effects on endothelial dysfunction, could initiate and maintain the process of atherosclerosis. But it cannot occur in just 20 minutes.

And even chronic exposure to secondhand smoke does not reduce the ability of the heart to pump. What reduces the ability of the heart to pump is injury to the cardiac muscle, such as occurs in a heart attack, with cardiomyopathy, with certain arrhythmias, with myocardial disease, with cardiac tamponade, or with ventricular hypertrophy or valvular disease. But secondhand smoke exposure does not reduce the ability of the heart muscle to pump. Chronic exposure could lead to a heart attack, and that could certainly reduce the heart's ability to pump. But this claim that only 20 minutes of secondhand smoke exposure can reduce the heart's ability to pump is not accurate.

The reference used to back up this claim is a study which shows that brief exposure to secondhand smoke decreases platelet sensitivity to prostacyclin.

But I don't think it's accurate to go from a study that showed that brief exposure to secondhand smoke decreases platelet sensitivity to prostacyclin to a claim that it reduces the ability of the heart to pump and increases the risk of a heart attack.

In fact, what the study showed was that the effects of brief exposure to secondhand smoke on platelet sensitivity to prostacyclin are transient, such that in passive smokers, a measurable decline in this sensitivity can be detected. However, in chronic smokers, there is no observed decline in platelet sensitivity, because presumably, the chronic and repeated nature of the exposure creates a condition under which platelets are constantly activated (see: Burghuber OC, Punzengruber C, Sinzinger H, Haber P, Silberbauer K. Platelet sensitivity to prostacyclin in smokers and non-smokers. Chest 1986; 90:34-38).

As the study concluded: "This study indicates that platelets of chronic smokers are less sensitive to exogenous PGI2 than platelets of non-smokers. In addition, active as well as passive smoking decreases platelet sensitivity to PGI2 in non-smokers, whereas chronic smokers exhibit no further decline."

Thus, the study actually demonstrates just why it is that a brief exposure to secondhand smoke does not cause atherosclerosis, while a prolonged and chronic exposure may.

The study actually uses the sensitivity to prostacyclin of briefly exposed nonsmokers to provide support for the hypothesis that altered platelet function in smokers plays a role in the development of atherosclerosis in these individuals.

2. "Only 30 minutes of secondhand smoke exposure can cause narrowing of blood vessels, restricting the flow of blood and contributing to hardening of the arteries."

You cannot develop atherosclerosis in 30 minutes. If that were the case, you would see lots of young people dying from smoking as well as from secondhand smoke.

Why is it that most smokers who develop coronary artery disease don't show evidence of this disease until they are at least 40 years old?

The answer is that it takes many years to develop atherosclerosis. It is not a process that happens overnight, and certainly not in 20 minutes.

In fact, it usually takes something on the order of a 90% stenosis (i.e., narrowing) of the coronary arteries before the blood flow is restricted enough to cause a heart attack. Obviously, that cannot happen in 20 minutes.

The fact sheet backs up this claim by citing a study which shows that 30 minutes of exposure to secondhand smoke can cause endothelial dysfunction, as measured by coronary flow velocity reserve (CFVR), in nonsmokers to the same degree as seen in smokers (see Otsuka R, Watanabe H, Hirata K, et al. Acute effects of passive smoking on the coronary circulation in healthy young adults. JAMA 2001; 286:436-441).

But endothelial dysfunction is not the same thing as narrowing of blood vessels, restricted blood flow, and hardening of the arteries (atherosclerosis).

In fact, what endothelial dysfunction measures is the early process of atherosclerosis. As the authors (Otsuka et al.) concluded: "The present findings suggest that reduction of CFVR after passive smoking may be caused by endothelial dysfunction of the coronary circulation, an early process of atherosclerosis, and that this change may be one reason why passive smoking is a risk factor for cardiac disease morbidity and mortality in nonsmokers."

What this means is that acute exposure to secondhand smoke can result in endothelial dysfunction in nonsmokers that if prolonged and repeated over a long time, could eventually result in atherosclerosis and heart disease.

In other words, this study provides a potential mechanism for the observed increase in heart disease risk among passive smokers. It provides biologic plausibility for a causal relationship between exposure to secondhand smoke and heart disease. But it does not suggest that a nonsmoker could develop atherosclerosis as a result of a 30 minute exposure to secondhand smoke.

3. "In that same 30 minutes, changes to your blood boost your risk of building up fat deposits that could lead to heart attacks and strokes."

For the same reasons as above, this claim is also inaccurate. You simply cannot develop fat deposits that could lead to heart attacks and strokes from a 30 minute exposure.

The study the fact sheet cites to back up this claim is a study which shows that brief exposure to secondhand smoke causes cellular and biochemical changes that are seen in atherosclerosis. In other words, similar to the effect of passive smoking on endothelial dysfunction and platelet activation, the effects of passive smoking on low density lipoprotein (LDL) metabolism and cellular accumulation demonstrate a potential biologic mechanism by which chronic exposure to secondhand smoke could lead to atherosclerosis.

Instead of concluding that 30 minutes of secondhand smoke exposure increases the build-up of fat deposits that could lead to heart attacks and strokes, what the study actually concluded was that: "Exposure of nonsmoking subjects to secondhand smoke breaks down the serum antioxidant defense, leading to accelerated lipid peroxidation, LDL modification, and accumulation of LDL cholesterol in human macrophages." (see Valkonen M, Kuusi T. Passive smoking induces atherogenic changes in low-density lipoprotein. Circulation 1998; 97:2012-2016).

4. "After 120 minutes of exposure, your heart rate variability is reduced, increasing the chance of an irregular heart beat that can itself be fatal or trigger a heart attack."

While the first part of this statement is accurate, as there is evidence that acute exposure to secondhand smoke does reduce heart rate variability, the second part of the statement is false. This short-term decrease in heart rate variability does not increase the risk of an arrhythmia (irregular heart beat) that could be fatal or trigger a heart attack.

If this were true, you would see nonsmokers dropping dead all the time after acute exposure to secondhand smoke. If this were true, you would see nonsmokers suffering fatal arrhythmias induced by brief exposure to secondhand smoke. But in the sum total of my years of clinical experience, I have never heard of a nonsmoking patient suffering a fatal or catastrophic arrhythmia from acute exposure to secondhand smoke.

Also, if this were true, it would be unethical to do this type of research without doing cardiac monitoring of human subjects and having resuscitation equipment available. You couldn't just walk into the Salt Lake City airport (as was done in the relevant study) and ask subjects to spend 2 hours in a smoking area, measure a decrease in heart rate variability that could cause a fatal arrhythmia and then discharge those subjects.

The study cited by the fact sheet to back up this claim is a study of the effects of a 2 hour exposure in a smoking area at Salt Lake City Airport on heart rate variability and it does show that the exposure alters heart rate variability. However, the clinical significance of this finding with regards to an acute exposure is nil. The relevance is in terms of the effects of chronic exposure. Once again, this study provides a potential mechanism for the observed increase in heart disease risk among individuals chronically exposed to secondhand smoke (see Pope CA, Eatough DJ, Gold DR, et al. Acute exposure to environmental tobacco smoke and heart rate variability. Environmental Health Perspectives 2001; 109:711-716).

It is important to point out that air pollution also decreases heart rate variability, in a very similar way to the findings observed due to secondhand smoke. There are at least 3 studies which have documented that particulate air pollution changes heart rate variability, just like secondhand smoke; however, one wouldn't conclude that exposure to air pollution may trigger a fatal or catastrophic arrhythmia. (see Liao D, et al. Environmental Health Perspectives 1999; 197:521-525; Gold DR et al. Circulation 2000; 101:1267-1273; Pope CA et al. American Heart Journal 1999; 138:890-899).

If the fact sheet is corrected, please let me know and I would like to highlight that on my blog and praise the organization for fixing it.

Best regards,Mike

Michael Siegel, MD, MPHProfessorBoston University School of Public Health

Wednesday, June 21, 2006

In a letter sent to the editor of the New York Times and released on the Action on Smoking and Health (ASH) web site, ASH calls on physicians who suspect that parents of their pediatric patients are smoking in the presence of these children after being informed of the health risks be reported to authorities for investigation of child abuse.

The letter comes in response to a June 14 Wall Street Journalcolumn by a pediatrician who argued that smoking around children is "a legal form of child abuse." The pediatrician writes: "I've had patients leave my practice because we've told them that they were harming their children's health and their own by smoking. ... I feel bad for the kids, but I don't miss dealing with their stubborn parents. I'd like to see what six months in a non-smoking foster home would do for the breathing of some of my pediatric asthma patients. Maybe that would be a wake-up call for their parents."

ASH writes: "Dr. Brewer writes very movingly about children brought to his office with serious breathing problems and other conditions caused by parents smoking around them, and says that talking -- even "a more assertive approach" -- often doesn't get them to change their behavior, which he characterizes as "a legal form of child abuse." It is!

We recommend that if talking doesn't work, physicians should file a formal complaint of suspected child abuse (or child neglect or reckless endangerment) the same as they would if a child were regularly being subjected to other toxic and carcinogenic substances like asbestos or benzene. Courts and social welfare agencies are beginning to react, and have issued thousands of orders prohibiting smoking in a car or home when a child is present.

The law not only requires physicians to report cases of suspected child abuse, but also shields them from legal liability for doing so."

The Rest of the Story

I have already discussed the numerous reasons why treating smoking around children as child abuse is a terrible idea and why it would cause irreparable harm to many kids, not the least of which is the fact that the ultimate remedy in child abuse proceedings - removal of children from their parents - would be a disastrous outcome for children exposed to secondhand smoke.

Here, I want to make several points. First, the argument that the pediatrician makes reveals exactly why ASH's recommendation, if heeded, is likely to harm childrens' health. He mentions that patients have left his practice because he has told them they were harming their children by smoking. Can you imagine what would happen if parents were to be reported to authorities for smoking around their children? They would be extremely reluctant to present to physicians for medical care for their kids. The action that ASH is recommending would essentially eliminate or severely limit access to needed health care for large numbers of the nation's children.

Second, it is quite scary to me that a physician is actually suggesting that kids should be removed from their parents as a health promotion intervention. There are lots of ways available to us in public health to motivate people to change health behaviors, but forcibly breaking up families and removing children from their parents is not one of them.

Third, you cannot have a "legal" form of child abuse. By definition, child abuse is illegal. So if you want to make smoking around children a form of child abuse, then by definition, smoking around children must be unlawful. If ASH is admitting that smoking around children is entirely lawful, then there is no argument that it should be reported to authorities as child abuse. It clearly is not. What ASH would have to argue is that smoking around children is actually not lawful under current child abuse law.

You can't have it both ways. You can't try to avoid being shunned by the public by arguing that you are not suggesting that smoking around children is unlawful, but then suggest to physicians that they should report parents who are complying with the dictates of law for child abuse.

The very fact that these groups acknowledge that smoking around children is lawful demonstrates the recognition by society that child abuse laws are not and were never intended to apply to widely recognized legal behaviors like smoking. We cannot and should not re-interpret laws in such a wild manner simply because some fanatical anti-smoking groups are unable to understand the attributes of child abuse.

Finally, it is important to note that ASH is actively pushing this aspect of the anti-smoking agenda. And that nobody in the anti-smoking movement is speaking out against them. This means that treating parents who smoke around their children as child abusers is now officially a part of the anti-smoking agenda. That's an agenda with which I don't want to be associated.

Tuesday, June 20, 2006

In yet another example that illustrates the tendency of the anti-smoking movement to silence dissent rather than tackle the substantive issues being put forward by the dissenter, a message sent to a list-serve of which I used to be a member asked those who know me to give me a good talking to and whip me into shape. (This is the list-serve I was thrown off of several months ago for "interfering" with the quality of the list-serve discussion by disagreeing with some of the dogma of the movement, not the list-serve I was thrown off of three weeks ago).

The message addressed an op-ed piece I published in the Boston Herald which argued that policies by which employers refuse to hire smokers (or fire existing smokers) are discriminatory and unduly intrusive of individual privacy and are therefore not justified from a public health perspective. The piece also suggested that broad outdoor smoking bans which regulate smoking in areas where nonsmokers can easily avoid smoke exposure are going too far, as they are not supported by any scientific evidence of a substantial threat to public health that would justify the use of the state's police power to interfere with individual liberties.

"I am sending you a letter by Michael Siegel in a Boston paper. He is really going to hurt the smoke-free movement. I hope some of you that know him will talk to him about the damage he is doing. It is going to make it more difficult to get smoke-free bans."

The Rest of the Story

What is most interesting about this communication to the list-serve is that it asks those who know me to try to silence me not because anything I'm saying is inappropriate or wrong, but simply because people don't like what I'm saying and feel it is going to hurt the cause. The note does not point out a single problem with my argumentation or even suggest that my arguments do not hold up. But people don't like what I'm saying, so I must be silenced.

I apparently need a good scolding from my colleagues because I have gotten out of line and criticized our strategies and tactics to achieve our goals. I need a talking to because I have pointed out that some of what we are communicating to the public is fallacious. I need to be whipped into shape because I am opposed to discriminating against smokers in employment. And I need to be kept in line because I came to the conclusion that there is not adequate scientific evidence of the harms of outdoor exposure to secondhand smoke to justify policies that ban smoking in places where nonsmokers could easily avoid exposure, such as streets, sidewalks, and parking lots.

Let me make one thing perfectly clear. What is hurting the cause is not my demanding a higher standard of scientific integrity and public health accountability. What is hurting the cause is the complete loss of a science base and solid public health policy analysis to justify and support our actions and our agenda. What is hurting the cause is our use of junk science to promote smoking bans. What is hurting our cause is the fanaticism in the movement, which is going to make the public think that we are crazy zealots, rather than evidence-based public health advocates. What is hurting the cause is our increasingly outrageous "scientific" claims, which are going to destroy our credibility and make it impossible to convince anyone of anything, even when it is scientifically solid.

The personal attack on individuals who dissent, based on the contention that what they are doing is "hurting the cause" is simply a tactic used in the anti-smoking movement to silence dissenters. By heaping the movement's scorn on them, it makes it close to impossible for them to express their opinions. The technique might work on me, except for the fact that I'm not a public health advocate - I'm a professional writer for pro-smoking groups!

About Me

Dr. Siegel is a Professor in the Department of Community Health Sciences, Boston University School of Public Health. He has 32 years of experience in the field of tobacco control. He previously spent two years working at the Office on Smoking and Health at CDC, where he conducted research on secondhand smoke and cigarette advertising. He has published nearly 70 papers related to tobacco. He testified in the landmark Engle lawsuit against the tobacco companies, which resulted in an unprecedented $145 billion verdict against the industry. He teaches social and behavioral sciences, mass communication and public health, and public health advocacy in the Masters of Public Health program.